The medical management of coronary artery disease (CAD) involves several classes of medications, each with specific indications based on patient characteristics and clinical presentation.
Antiplatelet therapy
- Aspirin: Low-dose aspirin (81 mg; 75–100 mg) is recommended to reduce atherosclerotic events in patients with chronic coronary disease without any indications for oral anticoagulant (OAC) therapy
- Dual antiplatelet therapy (DAPT): DAPT with aspirin and clopidogrel is recommended for 6 months after percutaneous coronary intervention (PCI), followed by single antiplatelet therapy to reduce major adverse cardiovascular events and bleeding events . Extended DAPT beyond 12 months for up to 3 years may be considered in patients with a previous myocardial infarction and low bleeding risk
- P2Y12 inhibitors: P2Y12 inhibitor monotherapy for at least 12 months may be considered to reduce bleeding risk in selected patients treated with PCI and a drug-eluting stent who have completed a 1–3-month course of DAPT
- Vorapaxar: Adding vorapaxar to aspirin therapy may be considered to reduce major adverse cardiovascular events in patients with a previous history of myocardial infarction without a history of stroke, transient ischemic attack (TIA), or intracerebral hemorrhage
Anticoagulant therapy
- Rivaroxaban: Low-dose rivaroxaban 2.5 mg BID may be added to aspirin 81 mg daily for long-term reduction of risk for major adverse cardiovascular events in patients with chronic coronary disease with no indication for therapeutic direct oral anticoagulant (DOAC) or DAPT and at high risk of recurrent ischemic events but low-to-moderate bleeding risk
Beta-blockers
- Indications: Beta-blockers reduce the risk of future major adverse cardiovascular events, including cardiovascular death, in patients with chronic coronary disease and left ventricular ejection fraction (LVEF) ≤ 40% with or without previous myocardial infarction . They are also recommended in patients with chronic coronary disease and LVEF < 50%
- Reassessment: The indication for long-term (>1 year) use of β-blockers should be reassessed in patients on β-blocker therapy for previous myocardial infarction without a history of or current LVEF ≤ 50%, angina, arrhythmias, or uncontrolled hypertension
RAAS inhibitors
- ACEIs or ARBs: ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) reduce cardiovascular events in patients with chronic coronary disease who also have hypertension, diabetes, LVEF ≤ 40%, or chronic kidney disease (CKD)
Antihypertensive therapy
- ACEIs, ARBs, or β-blockers: These are recommended as first-line therapy for compelling indications (such as recent myocardial infarction or angina) in adult patients with chronic coronary disease and hypertension (systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 80 mmHg), in addition to nonpharmacological strategies
Statins
- High-intensity statins: Some guidelines recommend initial treatment with high-intensity statins to achieve at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C)
In conclusion, the choice of medication in CAD is guided by the patient's clinical profile, risk factors, and specific clinical scenario. The goal is to reduce the risk of major adverse cardiovascular events while minimizing the risk of adverse effects.